Aseptic Care.—Place patient on a clean bed pan. It need not be sterile. Drape with a sheet and arrange it so the fold may be easily raised by nurse’s elbow. Have sterile basin with cotton pledgets to be filled with solution of lysol 1 per cent. Lysol must be put in basin first and the water added. Take to bedside. Nurse scrubs her hands ten minutes with a sterile brush, hot water, and green soap. Use no towel, no gloves. Keep hands wet and clean. Cleanse vulva with wet pledgets from above downward. Apply sterile pad.

Sterile Specimen.—To get a sterile specimen of urine without catheter, give aseptic care, tampon vagina with large pledget of sterile cotton. Have patient urinate in a sterile basin. Remove tampon.

Sterile Specimen from Child.—Take a glass test tube and thrust its round end through a hole in a square piece of adhesive plaster. Push it down until the plaster is caught and stopped by the enlarged rim at the mouth of the tube, with adhesive side of plaster on same side as opening of tube. Fasten the tube over the male penis or female vulva by applying the plaster to the surrounding skin. Leave until full.

Aseptic Douche.—Boil douche point and basin. Leave point in sterile basin. Fill douche can with sterile water, temperature 104° to 110° F. Put clean bedpan under patient who is draped with a sheet. Have at hand a sterile basin containing solution of lysol 0.5 per cent, or boric acid 5 per cent in which cotton pledgets are immersed. Scrub the hands as for aseptic care. Cleanse the vulva with cotton pledgets, washing always toward the anus, and use each pledget but once. Adjust the douche point and introduce it just inside the labia. The douche can should be only a trifle higher than the pelvis. When can is empty, apply a sterile pad.

If the douche is to be used as a deodorant after the fifth day of the puerperium, either of the following solutions may be employed: Potassium permanganate, 1:5000; formaldehyde 1 dram to quart, or chinosol 1:1000.

The vaginal douche may be used in cases of gonorrhoeal infection in pregnancy during the last weeks, in the hope of avoiding infection of the child’s eyes.

It is given like the aseptic douche (q. v.) with potassium permanganate 1:5000, or chinosol 1:1000. It should be hot (112° to 120° F.), and be begun not long before term, so that in case labor comes on, the danger to the child will be minimized. The reservoir must not be too high, nor the douche point inserted much beyond the labia. The woman should be on her back and the douche point should be rubber or glass.

Removal of Sutures.—On, or about, the tenth day the removal of sutures is required.

The nurse will sterilize by boiling, 1 pair of long-handled, sharp-pointed scissors, 1 pair of tissue forceps, and if the sutures extend far into the vagina, a vaginal retractor.

A basin of lysol solution (1 per cent) with cotton sponges, a sterile towel to lay the instruments on, a dish to receive the soiled dressings, sutures and discarded sponges, completes the arrangement.

The patient is now draped with sheets as for examination. The doctor prepares his hands as for operation. The nurse holds the limbs of the patient in lithotomy position and the operation is begun.

Uterine Tampon.—Packing the uterus is mostly employed for hÆmorrhage after labor. The patient, therefore, has been prepared and only fresh sponging with lysol solution is required.

The instruments are, 1 vaginal retractor, 1 pair of dressing forceps, 1 vulsellum forceps and a jar of gauze, four to six inches wide and ten or twelve feet long. Always use a single continuous strip. A very large quantity is necessary to fill the uterine cavity. Any sterile gauze may be used, but weak iodoform is satisfactory.

The vagina is held open with retractors, the cervix seized with a tenaculum and pulled down, the end of the gauze strip is then carried into the uterus as far as the fundus, the dressing forceps withdrawn and a new length carried in until the cavity is packed tightly from the fundus clear to the os.

Care must be taken that the strip of gauze is not contaminated by vaginal contact during the introduction. A pad and binder are now applied. If no instruments are at hand, or there is not time to sterilize, then the nurse can grasp the fundus through the abdominal wall with her hand and push the cervix down to the vulva where the gauze can be pushed in by the doctor’s fingers, if necessary.

The tampon acts as a hÆmostatic through its direct mechanical pressure, and dynamically by stimulating the uterus to contract. It should be removed in from twelve to twenty-four hours.

To tampon the vagina the woman lies on her back across the bed, with her feet on the knees of the doctor, who sits facing her. A sterile retractor holds back the posterior wall of the vagina.

With a pair of dressing forceps the doctor seizes the pledgets of cotton or gauze out of the lysol solution and carries them one by one as far as they will go, in various directions around the cervix. One is pushed forwards toward the bladder, the next back toward the rectum, the next in the middle, and so on until no more can be introduced. A pad and binder are applied tightly.

The uterine douche is sometimes employed for hÆmorrhage. The field of operation and the doctor’s hands are prepared as usual. The nurse cools the boiled douche water down to 120° F. and if ordered, adds 2 drams of sterile salt to each quart.

The instruments are a vaginal retractor, a long uterine douche point, and one vulsellum forceps.

The cervix is seized and brought down, the long douche point connected with the tube from the reservoir is carried to the fundus and the water started. Care must be used that the return flow is free and unobstructed.

This method is most satisfactory in uterine hÆmorrhage after the uterus has been entirely emptied. It stimulates a prolonged and profound uterine contraction.

Intravenous Injections.—The vein in the front of the elbow is usually chosen. (Median basilic or median cephalic.) A rubber bandage or tourniquet is wound tightly about the middle of the upper arm to make the veins stand out prominently. The surface of the skin should be sterilized for operation by scrubbing with green soap and hot water and rinsing with 50 per cent alcohol, followed by 1:2000 solution of bichloride, or by the application of tincture of iodine.

The hypodermic needle is then introduced after expulsion of all the contained air and the piston is drawn up until the blood enters. This assures the operator that the needle has entered the vein. The bandage is now loosened and the solution of the drug is introduced very slowly.

Intravenous infusion or transfusion is given in the same way. The fluid (normal saline?) must be running from the needle as it is introduced.

Hypodermoclysis is the introduction of normal saline solution, under the skin, or under the breasts. The solution may be transfused also into a vein.

By this operation, the quantity of fluid in the vessels is greatly increased and a circulatory stimulant is provided. Normal saline also promotes diuresis and aids in the removal of wastage.

The principal dangers arise from too great rapidity or too large a quantity of the flow.

The skin should be sterilized at the point of attack by a coating of tincture of iodine.

The instruments required are, a bath thermometer, a douche can (fountain syringe) with long tubes and an aspirating needle. A hypodermic needle will do, but the reservoir must be well elevated since the caliber is so small. Ordinarily the reservoir need be held only two or three feet above the point of discharge. The water should be flowing through the needle when it enters the tissues. If the fluid is to be introduced under the skin, the best place is in the loose region between the hips and the ribs in front. If under the mammary gland, the needle must go below and under the gland from the outside edge, not into the gland. If into a vein, such additional instruments will be needed as a rat-toothed tissue forceps, a pair of sharp-pointed scissors, a knife and some fine catgut. From four to sixteen ounces of fluid may be used at a temperature varying from 105° to 110° F.

The openings where the needles entered are closed by cotton and collodion.

Curettage of uterus is done for abortion or puerperal sepsis when foreign fragments are left in the uterus. The room is prepared as for delivery.

The instruments are:

Rubber gloves should be worn both by nurse and physician as much for personal protection as for the patient’s safety. In many cases of incomplete abortion or of puerperal sepsis the endometrium is more satisfactorily curetted with the gloved fingers.

Abortion may be indicated in many of the early complications of pregnancy, such as hyperemesis, nephritis, uncompensated heart lesions, tuberculosis, insanity, hydramnios, incarcerated retroversions of the uterus and the presence of hÆmorrhage. These cases require the operation to be undertaken and finished by the doctor, but other conditions develop wherein, without volition on the part of the patient or doctor, the abortion begins. Some may be saved, but at times the attempt is futile.

If the emptying of the uterus seems inevitable, the function of the physician is to see that the process is finished as quickly and cleanly as possible.

This may be done in the early stages by packing the cervix and vagina with iodoform gauze and administering ergot in twenty-five drop doses thrice daily.

In case of dangerous hÆmorrhage from spontaneous abortion, the vagina can be tamponed with cotton pledgets or gauze by a clean nurse while awaiting the arrival of the doctor.

When the uterus has partially emptied itself and the retained fragments prevent the complete contraction and allow of serious bleeding, or if the fragments are septic, then their removal is required. This is done by the finger or curette.

The preparation of rooms, patient and doctor are the same whether the operation is for therapeutic or incomplete abortion. These have been described.

The instruments are:

The induction of labor at or near term is done for pelvic contraction, maternal disease, for danger threatening mother or child, or to avoid the birth of a post-mature child. A variety of methods may be employed, but the Vorhees bag is best.

Technic.—Assemble, and sterilize by boiling twenty minutes, a Vorhees bag No. 3 or 4, Simon speculum or vaginal retractor, 1 pair long Pean forceps, 2 pairs vulsellum forceps, 1 dressing forceps, 2 pairs compression forceps, 1 Goodell dilator, 1 tenaculum forceps, Davidson hand bulb syringe with glass tubes and rubber connections for the bag.

Patient, prepared as for delivery, is placed upon the table in exaggerated lithotomy position. Stirrups will serve.

The vagina is retracted, a smear made from cervix, and the mucous membrane wiped clean with pledgets of gauze on forceps.

AnÆsthesia is only occasionally necessary even in primiparas.

Before using, the apparatus must be tested by forcibly filling the bag with sterile solution.

One lip and sometimes both are seized by vulsellum forceps and brought down. Usually, even in primiparas, the os is sufficiently patulous to admit the bag—if not, dilate.

The bag, emptied of residual air and fluid, is rolled up into a compact mass like a cigarette, seized with Pean forceps so that the tips extend just to the end of the bag. Turn the concavity of forceps toward patient’s left leg and introduce. As the bag enters turn the mass to the left—a quarter turn—so that when operation is completed the forceps curve faces upward. Release the lock on forceps. Connect the tube of the bag with syringe tube and force the solution slowly into bag. Pean forceps may be removed as bag fills. Remove vulsellum. Tie tube of bag with tape when bag is full—disconnect syringe. Put sterile pad on either side of tube.

If pains do not start within an hour, or if compression is desired as in placenta prÆvia or a more rapid dilatation, then a weight of one or two pounds is attached by a tape to the protruding tube and passed over the foot of the bed.

Digital dilatation of cervix may be indicated in cases of rigid os or where prolonged labor or some danger to mother or child requires the hastening of the delivery.

No instruments are needed, but a complete anÆsthetic is necessary.

Thorough asepsis must be observed. The patient’s genitals and the doctor’s hands are prepared as described for labor, and rubber gloves are imperative.

The gloved hands and the vagina and vulva are well rinsed with lysol solution 1 per cent. The operation must be done carefully, patiently and gently, lest the cervix be lacerated.

The hand is introduced into the vagina, and first the thumb and index finger are introduced into the os and separated as widely as possible, then the second finger and so on, until the dilatation is complete. (Hirst’s method.)

Another method is the introduction of the tips of both index fingers, back to back. Force exerted will dilate the canal so second fingers may also be inserted. Then patiently and gently the rigid ring of the os is overcome. (Edgar’s method.)

Episiotomy.—This is a clean incision of the vulva, which is done to avoid an apparently inevitable and ragged tear of the perineum.

The instruments required are either a blunt tipped knife or a pair of blunt scissors.

The operation may be done on one or both sides depending on the amount of room required. The incision begins at a point just above the lower third of the vulvar outlet when distended by the head, and passes obliquely downward and outward. This severs unimportant tissues only, instead of allowing the valuable perineal body to suffer. It makes a clean wound that heals readily, instead of a ragged tear through bruised tissue. The cut is high enough to be free from the constant bath in infectious lochia, which troubles the healing of the usual perineal laceration.

Rectal Infusion (Drop Method).—A douche bag containing normal saline solution is hung near the bed and kept warm with an electric pad, a hot flatiron, or by a hot water bag on either side. The tube ends in a catheter which is inserted into the rectum. The tube is clamped so that only a drop of solution can escape each second.

Wet packs are both sedative and antipyretic and may be employed for a local or a general effect.

For bronchitis the pack may be applied to the chest only as follows: The child (or adult) is stripped in a warm room (75° F.) and the chest swathed front and back with a thick towel wrung out of hot water (temperature 105° to 110° F.) Over this a woolen shirt may be drawn or a blanket wrapped, and the patient put to bed. After six or eight hours, the dressing is removed in a warm room, a hot bath administered, and the body well rubbed with alcohol, and dried. The treatment may be repeated if necessary. Do not burn the patient by applications too hot.

The general pack is most serviceable in reducing temperature and producing a diaphoresis to relieve the kidney and cleanse the system, as in eclampsia. For this purpose the entire body, naked, is rolled in a sheet wrung out of hot water and then put between heavy blankets in bed. The pulse should be taken frequently and the temperature recorded at intervals. A cool application to the head is very soothing.

The patient sweats profusely and hot drinks may be given to promote a more abundant diaphoresis. Usually the patient drops off to sleep as the fever subsides. Twenty to forty minutes is the average duration of such a treatment.

When the pack is removed, the patient is wrapped at once, without drying, in warm blankets, and left for an hour or so.